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What’s Next for Hospital Medicine?


 

At the Medical University of South Carolina (MUSC) in Charleston, a familiar scene plays out in the hospitalist program. New hospitalists express an interest in a certain area and the university tries to accommodate them, making time for them to pursue additional training as they juggle the daily demands of treating patients, says Patrick Cawley, MD, MBA, SFHM, associate professor at the university and a former SHM president.

"We try to have a personal growth plan for each hospitalist that aligns with their interest," Dr. Cawley says. "So if we have a hospitalist that’s very, very interested in quality improvement, we’ll seek out opportunities to get that hospitalist experience, and start with smaller projects and then bigger projects."

As the field of HM hits a notable mark in its history—it’s been 15 years since the term "hospitalist" was coined—more advanced training will continue to emerge as a key issue and obstacle in the field, say experts who were asked to take a look into HM’s crystal ball.

They also predict continued growth of the field, with tens of thousands of new hospitalists emerging in the next decade or so. They also say that hospitalists will emerge as leaders in the application and use of new technology, and that there will be more demands placed on hospitalists to show their worth in hard data.

There also promises to be a growing presence of private management firms providing hospitalists to hospitals, which doctors both inside and outside of those firms say could have a beneficial effect on the overall quality of patient care.

I think there’s a recognition that [training] is important and that hospitals and hospitalists need to get better aligned. This is something that will continue to mature over the next 10 years.

-Patrick Cawley, MD, MBA, SFHM, associate professor, Medical University of South Carolina, Charleston, former SHM president

Father Time

For now, Dr. Cawley says, at MUSC and elsewhere, hospitalist programs are scrambling for time to enhance the skills needed to tend to increased demands.

"You have to carve out time. That’s literally what you have to do," he explains. "That’s expensive to take a doctor away from clinical service for a week, or an even an hour or two a week. I mean, somebody’s got to pay for that."

Training on hospitalist-specific management topics, he says, needs to evolve further. "I think there’s a recognition that this stuff is important and that hospitals and hospitalists need to get better aligned," he says. "This is something that will continue to mature over the next 10 years."

The range of tasks is growing ever broader for the hospitalist, and so the need for enhanced training is greater, says Larry Wellikson, MD, SFHM, CEO of SHM.

"They’re being asked to do bedside patient care, but they’re being asked to do more. They’re asked to be systems engineers, they’re asked to be safety experts, they’re asked to be the information manager, if you will, the IT guys," he says. "These skills they have not been trained to do and they need … either to say, ‘No, I can’t do that because I haven’t been trained,’ or they need to go and look where they can get that expertise.

"That’s what we try to do at SHM, with our Leadership Academy and our Practice Management Academy."

Listen to Dr. Cawley

Frank Michota, MD, FHM, director of academic affairs in the Department of Hospital Medicine at The Cleveland Clinic, says that one of the biggest challenges the field needs to tackle over the next several years is to better standardize the education of hospitalists, saying there is "incredible inconsistency from hospitalist to hospitalist in terms of knowledge base, experience and … understanding the scope of practice."

"We continue to have significant variation in hospital practice models and the types of measurements that are available to those hospitalists for practice improvement," he says. "We continue to see significant turnover in the field with kind of a lack of maturity"—and not the kind of experience base that "you would like to see 15 years in."

"There is really no confidence that everyone at the base of that iceberg will ever make it to the tip because it’s still not viewed by many who entered the field as being a long-term career choice," Dr. Michota says. For many, he said, it is "a look-and-see proposition."

CERTIFICATION BY 2025?

For Now, It Appears Unlikely

HM came into its own quickly, growing at a pace that even its biggest supporters might not have foreseen. So will the next 15 years be the period when an HM certification board is formed? Will there be full certification for hospitalists beyond the Focused Practice in Hospital Medicine pathway offered through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification process?

As of now, probably not.

Dr. Wellikson, SHM’s CEO, says there are no plans for a certification board at this point. And opinions vary as to whether the field should have its own certification.

Dr. Wachter, ABIM’s chair-elect, says there will be refinements to the Focused Practice pathway, but that a subspecialty certification for HM probably wouldn’t happen until "unique training programs emerge," which he says is unlikely in the next several years.

"We’re pretty comfortable that we have created a pathway for hospitalists to demonstrate their focus on hospital medicine and their expertise borne of their experience," he says.

Dr. Michota says certification would reflect the depth of knowledge needed for today’s hospitalist. "The one thing that emergency medicine had by 15 years that we don’t is a board of emergency medicine, and they had the establishment of training programs that allowed for certification," Dr. Michota says. "I believe that if we’re going to meet the expectations for hospital medicine, we can’t just know everything that a general internal-medicine board would provide. We need to know it at the depth and breadth of the specialist. And we can, in fact, know more and be tested on more than what’s on the internal-medicine board exam."

Dr. Fisher agrees certification is an important step.

"My personal view is that there should be some certification to show that a hospitalist has completed formal training and can pass certain tests. Those tests might be knowledge-based, experience-based, or other," she says. "I believe there needs to be more formal proof that the training a hospitalist has received has been given by those who know how to train. Who performs this training has yet to be determined and may or may not follow current classic certification agency models."

Dr. Wachter says emergency medicine is different in that to be an emergency medicine doctor, you have to know internal medicine, some pediatrics, some surgery, orthopedics, and other areas, and that "to get those competencies, you needed a distinct training program."

"I don’t feel like hospital medicine is like that. My own feeling is that hospital medicine, for the care of adults, is to a large extent an extension of adult internal medicine," he says. "When we have surveyed hospitalists in the past, and asked them ‘What do you do for a living?’ ‘How well were you trained in those things in your residency?’ What they told us was, ‘I was trained very well to do the clinical portions of this job during my residency.’ Where they told us there were gaps was in less traditional areas of medicine," such as quality improvement (QI), communications skills, and leadership.

"It doesn’t strike me that to obtain those competencies, one needs to do a whole different training program than my internal-medicine training," Dr. Wachter adds. "But I do think that one has to modify internal medicine or pediatrics training to make sure that people have those competencies."—TC

All of this, he says, points to the need for a full certification process by an HM board.

"I don’t want to make it sound like it has not been an impressive evolution to this point, but I think if we are going to meet the expectations, we do have to do more than we’re doing now," Dr. Michota says.

Some of the gaps in training might be able to be filled by private hospital management groups, which have training programs for their doctors that are made possible by their scale and whose presence is predicted to grow over the next 15 years.

Robert Bessler, MD, who in 2001 founded Tacoma, Wash.-based Sound Physicians, which has become one of the largest private hospitalist organizations in the country, says private companies are able to conduct training that is impossible for many hospitals to conduct themselves.

"You’re going to get good people who are all of good training and good knowledge, but they’re not all going to have experience," he says, "and so what are the hospitals that are employing 50% of the hospitalists in this country going to do about that? It’s pretty much nothing. They’re going to occasionally send some people to conferences and hope—because they don’t have that infrastructure."

At teaching institutes like those at private firms, the process is sped up, Dr. Bessler adds.

"That’s why we built our hospitalists’ institute at Sound—to turn really good, quality doctors into effective hospitalists in a much more rapid fashion," he says. "Because before we built this, it was just get them involved and hope after a couple of years they’ve really become efficient. Our hospital partners and the patients can’t wait that long."

Robert Reynolds, MD, founder of PrimeDoc, an Asheville, N.C.-based company that provides doctors for 12 hospitalist programs and employs about 100 doctors, says there needs to be more focus on teaching the "realistic side of the business of medicine," as well as on quality outcomes and patient satisfaction. But he also doubts there will be much change in training.

"[From] my cynical side and the voice of experience, I don’t see any change in the near future," he says. "What we’re seeing now is physicians come out of residency with a good clinical base, but really having no idea of how the healthcare system works in a bigger picture, how it works as an industry. So we’re having to spend a lot of time and effort training physicians to start thinking like practicing physicians."

The experts all agree that there will be an increase in hospitalists being provided by private corporations. Dr. Reynolds says that trend will continue in part due to healthcare reform’s emphasis on outcomes for reimbursement and a corporation’s ability to assist with physician training, as well as data and reporting needs.

"More and more hospital compensation and physician compensation is going to be based on actual data, performance data," he says. "And in order to really do a good job of capturing and reporting that kind of data, you need enough size to support an IT system and training systems that will produce and capture the kind of data that will be necessary."

Erin Fisher, MD, MHM, a pediatric hospitalist at Rady Children’s Hospital in San Diego, says a major goal of the future should be to change the reimbursement structure "so that you have something that is reasonable and encourages appropriate testing, treatments, and coordination of our healthcare system in a systematic way, rather than pieces." In such a system, hospitalists might see something to prompt them to intervene in a preventive way.

"The bigger question is, can our healthcare system, in five to 10 years, change itself enough that it uses every episode of care as an opportunity to do preventive care and coordinate care in the best way?" says Dr. Fisher, an SHM board member.

Continued Growth?

There is agreement that the field will continue to expand, with SHM predicting that the number of hospitalists in the U.S. will reach 40,000 in the next several years, up from today’s 30,000 figure.

Dr. Wellikson says that the figure could rise to as many as 70,000 or more if specialty hospitalists—such as surgical hospitalists, neuro-hospitalists, and laborists—are included. Those hospital-based specialties are now only in their infancy.

"Everything you can see shows that people are still flocking into hospital medicine," Dr. Wellikson adds.

Hospitalists numbered in the hundreds just 15 years ago, so growth has been explosive the past decade. Dr. Cawley, however, says the pace of growth might be starting to slow already, shifting to undeveloped or underserved areas. "Hospitalist programs are at almost all the large [hospitals] and really the growth has been at the smaller hospitals in the last several years," he says.

Listen to Dr. Michota

With the projected rise of Medicare beneficiaries due to the aging of the baby-boom generation, use of hospitals is expected to skyrocket, meaning more hospitalists will be needed, Dr. Bessler says. He also cites data from the National Rural Health Association noting that 25% of the U.S. population lives in areas considered rural, but that only 10% of the physicians live in those areas, indicating a potential growth area for hospitalists.

"That would tell me that demand will continue to outpace supply," he says.

Mike Tarwater, a member of the board of the American Hospital Association and CEO of Carolinas Medical Center in Charlotte, N.C., agrees with Dr. Bessler. Even with the move toward more outpatient care, Tarwater says, the aging of the population will mean a higher demand for hospitalists.

I think that the primary-care physicians—either because of their love for it or their belief that it’s the better way to go with the treatment of their patients—are going to be really stretched to keep that ambulatory practice going and to get to round on patients in the hospitals.

-Mike Tarwater, board member, American Hospital Association, CEO, Carolinas Medical Center, Charlotte, N.C.

"I think that the primary-care physicians—either because of their love for it or their belief that it’s the better way to go with the treatment of their patients—are going to be really stretched to keep that ambulatory practice going and to get to round on patients in the hospitals," he says. "I think there’s going to be a continued growth of the trend that we’ve seen over the last 15 years."

That growth also will mean a greater emphasis on technology use, whether it’s technology used for quick diagnostics like portable ultrasound or more widely used and refined electronic health records (EHR)—or, as Tarwater describes, "probably things we don’t imagine today."

"Our doctors, more than any other doctors, are tech-savvy; they’re early adopters," Dr. Wellikson says.

Hospitalists likely will emerge as leaders in the adoption of new technology, several experts predict.

Without a doubt, I think that hospitalists are going to be a driving force in the adaptation of the electronic [health] record to the clinical care within their hospitals," Dr. Michota says.

As the needs of HM grow, and the field grows more complex, there will inevitably be more divisions and departments of hospital medicine in places where it is now only a section, Dr. Cawley says.

"When you’re a division or a department, you have more autonomy over your own future, so I see this happening," he says. "I think more and more will carve themselves out of general internal medicine, and a lot of that will come because of a demand for more independence and greater autonomy." TH

Thomas R. Collins is a medical writer based in Florida.

More Value, More PATIENTs, More Technology

HM Pioneer Looks Into Crystal Ball

Robert Wachter, MD, MHM, one of the physicians who coined the term "hospitalist" 15 years ago and regarded as one of the field’s founding fathers, likes the idea of the field being a sentinel for the rest of healthcare. "It’s one of the fun things about being in the field," says Dr. Wachter, professor and chief of the division of hospital medicine at the University of California at San Francisco. "If you look at what’s happening to hospitalists in the next two to four years, you can pretty much figure out what’s going to happen to the rest of medicine in five to 10 years.

"We’re that camel’s nose."

With that in mind, what does Dr. Wachter predict for the next 15 years of HM? Here are his top three prognostications:

  1. A shift from the pressure to improve quality and safety to pressure to improve value, with more emphasis on cost and waste reduction. "Hospitalist groups that are effective at [quality and safety] will continue to be popular in their organization, while hospitalist groups that aren’t will find that their standing is compromised," he says.

    How that is done will vary from institution to institution. It will require a complex process of literature and creation of algorithms, he adds, "but also rolling up your sleeves and meeting with the right people, and working through the politics and diplomacy in order to get this work done."

  2. At teaching hospitals, a greater role for hospitalists to take care of patients who have traditionally been cared for by residents. This is borne of the new Accreditation Council for Graduate Medical Education (ACGME) rules for residents’ work hours and supervision, which will require more hospitalists to fill voids in patient care and supervisory roles.

    "If you like growth, that’s a great trend for hospitalists," Dr. Wachter says. "But if you’re in the business of trying to hire enough hospitalists to fill all your needs, it’s not that great because the demand curve is just tremendous; there’s a national shortage of hospitalists."

    The trend also will affect what "a faculty job looks like," because there will be more clinical needs that will take time away from more traditionally academic work, he explains.

    "Academic hospitals are not very good at creating satisfying, sustainable jobs that are largely clinical," Dr. Wachter says. "So how do you make sure that those people have fulfilling jobs, that they don’t feel like second-class citizens, that they can get promoted if they do what you’ve asked them to do well? I think that’s a huge challenge for the field, but it is a challenge borne of a new imperative."

  3. A revolutionary move from a pen-and-paper hospital environment to a technology-driven workplace.

    "It will change the way we do our work," Dr. Wachter says, adding it will also mean other, more subtle changes.

    "It takes away the importance of geography to some extent," he adds. "I can be off in the doctor’s lounge or in my house and still do my work.

    "And so how do you retain or enhance the relationships that are so fundamental to providing good care? That’s not only between doctors and patients and families, but also between doctors and nurses, and each other."-TC

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